12060037CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 18840 PENDERGAST AVE CONTRACTOR: UW CONSTRUCTION PERMIT NO: 12060037
CENTER
OWNER'S NAME:
MOUNTAIN VIEW, CA 94040 PHONE NO: (408) 687-8282
❑ LICENSED CONTRACTOR'S DEECLARATION
License Class Lic.#
Contractor Date v 0�
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
918.
Signature Date
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
I, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
I certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If, after making this certificate of exemption, I
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
MECH r RESIDENTIAL COMMERCIAL r
JOB DESCRIPTION: REMODEL TWO (2)BATHROOM 80 SQFT AND REMODEL
KITCHEN 200 SQFT &REMOVE AND REPLACE WATER HEATER
WITH TANKLESS
Sq. Ft Floor Area: I Valuation: $20000
APN Number: 37533048.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued Date: 6:�,— 2'
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
Owner .
ate:
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of Nwrk's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Signature Date I Licensed
CITY OF CUPERTINO
M97"
FEE ESTIMATOR — BUILDING DIVISION
WdADDRESS:
'
18840 Gendergast Ave
DATE: 06/06/2012
REVIEWED BY: Sean
APN:
BP#:
*VALUATION: 1$20,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex
USE:
PENTAMATION 1 R3SFDRE
PERMIT TYPE: A
WORK
Remodel 2 bathrooms 80 sq ftand remodel kitchen 200 sq ft. Remove and replace water heater
SCOPE I
with tankless.
Alc h. P/on Check
Plumb. Plan Checkj 0.0 1 hrs $0.00
Elec, Plots Checlr
Abfech. NoWl Fee:
Plumb. Permit Fee: IPPERMIT
lake. Permit Pc'c:
01hc r A tee Ir. Insp.Other
E3-1-
Plumb Insp. 0.0 hrs $44.00
Usher Elec. Mspl
Ak'ch' hz p, Fee:
Plrnub, hr.rp. Per:
Elec. Imp, Fee:
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Puhlie Works, Fire, Sanitary Sewer District, School
nictrirt. otr_ )_ These foot are hosed an the nreliminary information available and are only an estimate. Contact the Dept for addn'I into.
FEE ITEMS (Fee Resohition 71 11)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
80 s.£
$588.00
Remodel, Bath (<=300 sf)
IREMRESBAT
i
Suppl. PC Fee: Q Reg. Q OT
10.01
hrs
$0.00
PME Plan Check:
$0.00
= s.£
$588.00
Remodel, Kitchen (<=300 sf)
1REMRESKIT
Permit Fee:
$0.00
Suppl. Insp. Fee:Q Reg. Q
OT
0.0
lu•s
$0.00
1= # Plumbing
$26.00 1PRWHEATR Water Heater
PME Unit Fee:
$0.00
PME Permit Fee:
$44.00
('u)tsInIctioti 1 ox.'
Administrative Fee:
IADMIN
$41.00
G
Work Without Permit? 0 Yes Q No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential
Building or Structure
1
G
i
0
Travel Documentation Fee: ITRAVDOC
$44.00
Strong Motion Fee:
IBSEISMICR
$2.00
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$132.00
$1,202.00
TOTAL FEE:
$1, 334.00
wj
Revised: 05/01/2012